Ruminations by a non-academic general surgeon from the heart of the rust belt.

Tuesday, August 19, 2008

Sports Hernia

Ian Kinsler, the second baseman for the Texas Rangers, just got put on the disabled list for the rest of the year because of a "sports hernia". Ian Kinsler can wield some wicked lumber. He leads the American League in hits and runs. So why is he out for the year? What is the deal with this "sports hernia" business? It just so happens that I had a conversation with my pretend friend the other day about this very issue. Here's a transcript.

Sports hernia? Sounds cooler than a regular old hernia.Let's get something straight. Sports hernias are not hernias. A hernia is an abnormal protrusion from one body cavity into another. Think of the body as multiple hollow cavities lined by muscle and tough fibrous tissue. Any weakness or defect in this lining can lead to a hernia. With true hernias, you'll see a bulge or a lump, especially with coughing or straining.

So sports hernias aren't a defect?Not at all. The actual name for the syndrome is athletic pubalgia. If you read twenty articles on sports hernia, you'll find 20 different descriptions of the cause and presentation. That's usually a red flag in medicine. It means, we don't know what the hell we're talking about.

How do you know if I have a sports hernia or a real inguinal hernia?An inguinal hernia is easily appreciated on physical exam. A bulge will be present at the external ring opening or the inguinal floor may protrude with coughing. Sometimes the findings are subtle but if there is any doubt, my policy is to assume that the patient's symptoms are likely secondary to some other cause. Sports hernias do not have consistently characteristic findings. Other than pain with palpation, you will not identify a bulge or protrusion.

What about Xrays?Sports hernias are a diagnosis of exclusion. MRI's and CT scans are done to rule the existence of other causes, like osteitis or muscle tears or inguinal hernias. There is no pathognomic radiographic finding.

What would do for a guy with a sports hernia?After first ruling the possibility of an occult inguinal hernia, I would simply recommend rest and NSAIDS and patience. My feeling is that this constellation of symptoms is best explained by some sort of muscle strain or ligamentous tear. The surgical repairs described in the literature usually involve reinforcing the inguinal floor with mesh, but there isn't a standardized approach. One wonders about placebo effects....

Then why are all these high profile athletes rushing off to surgery for their sports hernias?Because professional athletes don't like to hear that the pain they're having is some sort of vague, non-specific muscle strain that will only heal with months of rest. They want a solution. They want a plan of action. They want to get back on the field as soon as possible. So it's reassuring to find a surgeon who can tell them they have a "sports hernia" and that the treatment is a "special surgery". And that recovery from the surgery will take months.

Final thoughts?I dug this up out of the January 2008 edition of the Journal of the American College of Surgeons:

Interestingly, many authors describe tears in the muscle, fascia, or aponeuroses as the causes of groin pain. But the majority of general surgeons are trained to palpate or visualize wide holes or defects in the aponeuroses of the inguinal region. To a trained eye or finger, these small tears may appear as bulges or asymmetric findings on physical examination. On the other hand, these tears may not be diagnosed until surgical exploration is performed. Although several series describe a variety of tears and even microtears, there appears to be a lack of pictures or even line drawings detailing these injuries. Even using the magnification offered through laparoscopy, the literature does not provide a variety of pictures detailing these inguinal tears.

Sounds pretty shady to me. And here's Dr. David Farley from the Mayo Clinic:

The best treatment for sports hernias is nature's own -- to lay off the offending activity and rest for a period ranging from a few weeks to a few months. It is also useful to engage in exercises that strengthen the abdominal muscles and increase their flexibility. This course is especially effective for professional athletes; because they are young and strong, they tend to have tremendous recuperative powers. On the other hand, they also tend to be exceptionally eager to get back in the game and seek a quick fix.

But quick, reliable fixes are not to be had. While surgical procedures exist -- suturing the tear (if it can be isolated) or patching the area with a synthetic mesh -- they offer no guarantee of solving the problem or preventing its recurrence.

The surgeon who taught me the most about inguinal hernias when I was a resident, Keith Millikan MD, also didn't buy into the whole sports hernia deal. Until we get better evidence (randomized controlled trials) I suspect my management of chronic groin pain won't be changing anytime soon.

I've had this for a year now - going through physical therapy and trying to avoid surgery. I've stayed away from running for several months and just started running again and the pain returned. Looks like I might have to look into that surgery after all...

Excellent, persuasive post, doctor. I'm a 50-year-old hockey player (that's right) in pretty good condition. I believe I got my sports hernia by doing "power cleans," recommended by a professional hockey trainer. My form was less than textbook. I knocked off running and hockey for two months, then went back to hockey for three weeks. My attempts to ease back into running have not been successful. Now I've decided to take up to another month off. It's much better than it was, but I can still tell it's there. We'll see what happens.

I began having groin, testicular and rectal pain after a busy season doing triathlon. I am also a hockey player. I've seen several specialists who all tell me the same thing: Rest, ice and take tons of NSAIDS. I've done all of that for over 4 months now. My s/s are still the same. I've done rehab, stretching so on and so forth. My s/s are still unchanged. This has been since 2005. Imaging and x-rays all negative. All other pathologies ruled out. It would be funny to hear a doctor for a professional sports organization tell the star player that his s/s must all be in his head and that he shouldn't play anymore.....That doc would lose his job! Well I'm no star player for a pro sports team but I'm not an average joe either. I don't spend my days on the couch. I use my body and find my current condition unacceptable. It's unfortunate that my docs don't feel the same way I do. I've paid good money for someone to suggest that it must be in my head?.....Outrageous! I'm living with this condition not by choice but because I obviously haven't met the right doctor yet. Maybe he's coming in off the golf course soon.......I hope. Until then I'll choke down another 400 of Alleve.......Anyone know a real doctor who's actually interested??

RP, I would recommend you check out my blog: www.thegroinpaincenter.blogspot.com, there is a lot of different information there as well. I have quite a bit of info on two big time athletic pubalgia/sports hernia repair doctors there. In addition to them, there is also a couple other doctors (including one in Canada) who would probably be of interest to you. But if you read through my blog you might come up with some other ideas/directions you can go outside of those doctors as well. Good luck to you.

I have been experiencing groin pain for the last 13 months. i have been to 5 diffrent consutants and been told i have a "hip flexor" tear and that rest and rehab will relive it. that was around 9 months ago i have seen improvment but not much with any phsyical activity my groin will flare back up. This all happend when i was "squating" my max if anyone thinks i might have a sports herina i would glad to hear your opinion so i can get on my way to recovery.

I've been suffering from groin pain for the past 18 months now. Although I had been preparing to return to military training for several months, I sustained injury while moving, by lifting a large, heavy television up the last few stairs.

I saw doctor after doctor who said it's a groin pull, and rest/ice/motrin will fix me. After 9 months, I began physical therapy and even tried Prolotherapy (google for more info). That reduced the pain from walking and going up the stairs, but the pain would still continue if I did anything physical at all...sometimes it just wouldn't go away at all.

A few months later I saw a surgeon who said he thinks it's athletic pubalgia, but he only deals with normal hernia repair. I searched online and found Dr. William C. Meyers in Philadelphia, whom my specialist who performed Prolo on me later suggested. I just saw him yesterday and he recommended me for surgery. Unfortunately, many insurance plans don't cover the surgery which runs $15k, though I know someone with Blue Cross/Blue Shield who said his did. I am trying to schedule myself for surgery now, as I've seen 7 doctors and done 7 different treatments (rest, ice, motrin, massage, acupuncture, prolotherapy, and physical therapy) which have all been ineffective. When someone says "rest and patience", that doesn't cut it 18 months later. Many insurance plans claim that it is not medically necessary since it's not life-threatening, but who wants to live a life in pain, restricted from any physical activity?

Anyhow, supposedly Dr. Meyers is the best in the country, and his name pops up very frequently when searching for surgeons online. I'd suggest giving it a try. He's a doctor at Drexel University.

About two months ago I was injured in a Hockey game. Felt like a took a shot to the family jewels. I finished the game with that empty feeling you get when you take a shot to this area. The next morning I almost passed out from pain when I tried to get out of bed. I went to a couple friends who are Dr. and they couldn't diagnose it as a Herinia. So I did some research and came back to them and said I think it's a sports hernia and then believed I was correct even though they never heard of such an injury. It's been two months and the pain is better. I have decided not to continue playing sports until it is 100%. Does anyone know if it will heal on it's own. I'm trying to do some light stomach curls to strengthen the area and I'm stretching. Other than that I'm not sure what to do.

Ski season is around the corner and I want to make sure I'm 100% healthy.

If there is no palpable bulge but an inguinal hernia is suspected, say based on radiology results, how would you know if it is inguinal hernia or sports hernia? Also, does sports hernia happen to laymen as well?

Great writeup on sports hernia.I started going to gym from past a couple of weeks. But since yesterday or so, I am experiencing a kind of light pain in my lower abdomen. I get the pain when I bend over, cough, sneeze. Is this a symptom for sports hernia? Is there any treatment other than surgery? Please suggest. I am tensed.

Yeah- Another F'in KNOW IT ALL!It's such a joke to see people fighting over a health care system that is so ineffective. You can document if neccessary thousands of these cases where the pain has persisted 2-3 years..and surgery has proven successful in the 90 percentile range. Not life threateining ??It is certainly quality of life threatening and I would like to will the affliction on the writer of this peice. I am sure he would have no problem hypocritically dropping the 15k for surgery after 2 or more years of this persitent ailment.

I am excited to see a higher level of awareness of the "sports hernia" condition on the internet. I injured myself twelve years ago doing heavy lifting. All of the urologists I have seen can not find anything wrong with me despite a battery of tests and one told me it was all in my head. Many, many attempts to get back into running, weight lifting, etc., have all failed with the exception of swimming. I have found that stretching in the pool is very helpful and kicking while swimming does not cause the pain to flair up. Avoiding impact seems to be the key. The elliptical trainer is the next best exercise, but daily moderately intense training will cause symptoms to reappear within a few days. There is no question this takes time to heal, but I don't think it will ever completely heal on its own. The first five years were literally hell as I could not carry my toddlers across the mall on Sunday. Since then, it is always there in the background just waiting to show its ugly face. I searched the internet a few years ago and did not find much help. That has all changed now and today you can find much more information if you look hard enough - so don't give up. I have been in contact with a doctor in California and have a name of one in Philadelphia. Now I am finding more resources locally and I am once again hopeful. Thank you for this website and for all those who share their thoughts.

I don't agree with the doctor's beliefs. I have had groin pain for over fifteen months now. I have totally laid off the activity (running) that caused it. I have had X-rays, MRI's, injections, physical therapy, and lots of rest. Nothing has changed. If I could afford the 17,000 cost of the surgery, I'd have it tomorrow.

A year ago my 16 yro son started experiencing sever groin pain that would not go away. He did all of the conservative treatments with little relief. After seeing 7 specialists, one finally said he probably had a sports hernia. We found a surgeon who did the surgery for him. Our insurance denied it at first as "experimental". Needless to say I fought it and won. I say appeal it and go after the insurance company if you have been denied - state your case and have the surgeon help you with documentation proving why you need it. Its been 6 mo since the surgery and he still has some groin pain after working out and sports. However, it gets a little better each day. The surgeon said it can take up to a year for him to be 100% pain free. I highly recommend the surgery as an option if you have tried all other conservative methods. No one should have to live with groin pain every day.......and the surgery has helped my son who is a very athletic kid. Check out Dr. Cattey - in Milwaukee Wi for more info.

Great post! Im a soccer player and have had this for about 7 months now. I can say that this does respond to conservative treatment the kicker being that the program of rehab is designed specifically by someone who understands sports hernia and many of its characteristics. Many PTS will view it as an isolated adductor issue and prescribe the usual band work etc. The first and most important issue to address is the tissue quality or lack of caused by the compensatory mechanisms resultant of the injury. Get a foam roller, some tennis balls etc for self management and get a quality tissue therapist for some active release. The second issue is the strengthening of the "core". Firstly for some strange reason the core seems to be synonomous with the ab muscle alone, however in this instance the primary muscles needed to be worked are the hip extensors. Lower cross syndrome and anterior pelvic tilt seem to be common in suffers of this. The "core" work should consist of restoring length to the hip flexors, strengthening the extensors and trying to incorporate/ relearn theyre recruitment in activity.

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